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Free sample Questions and Answers to Nclex Rn 2011: New Q& A 2 13 2011

 

40. For a client who has ataxia, which of the following tests would

be performed to assess the ability to ambulate?

a. Kernig's

b. Romberg's

c. Riley-Day's

d. Hoffmann's

Answer: b

Rationale: Romberg's test is the ability to maintain an upright position without swaying

when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction,

is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.

41. A client admitted to a surgical unit for possible bleeding in the cerebrum

has vital signs taken every hour to monitor to neurological status. Which

of the following neurological checks will give the nurse the best information

about the extent of bleeding?

a. Pupillary checks

b. Spinal tap

c. Deep tendon reflexes

d. Evaluation of extrapyramidal motor system

Answer: a

Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches

as it becomes displaced by blood, tumor, etc.


42. Assessing for immediate postoperative complications, the nurse knows that

a complication likely to occur following unresolved atelectasis is

a. Hemorrhage

b. Infection

c. Pneumonia

d. Pulmonary embolism

Answer: c

Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated

along with vigorous treatment for atelectasis. Hemorrhage and infection are not related to

this condition. Pulmonary embolism could result from deep vein thrombosis.

43. A young client is in the hospital with his left leg in Buck's traction. The

team leader asks the nurse to place a footplate on the affected side at the

bottom of the bed. The purpose of this action is to

a. Anchor the traction

b. Prevent footdrop

c. Keep the client from sliding down in bed

d. Prevent pressure areas on the foot

Answer: b

Rationale: The purpose of the footplate is to prevent footdrop while the client is

immobilized in traction. This will not anchor the traction, keep the client from sliding

down in bed, or prevent pressure areas.

 

Respiratory Disorders NCLEX Review

1.    A Mantoux test signifies exposure to Mycobacterium Tubercle Bacilli. The test is read for how many hours after injection?
a.    1 hour
b.    12-24 hours
c.    48-72 hours
d.    2 hours

2.    A nurse is about to perform a Mantoux test. The test is done by using which route?
a.    Intradermal
b.    Intramuscular
c.    Subcutaneous
d.    IM with the use of Z-track method

3.    A client is suspected to have an HIV. The nurse knows that in the Mantoux test result, a client is considered positive with HV if he has an induration of:
a.    More than 10 mm
b.    3mm
c.    4 mm
d.    5 mm

 

Answers: 1.    Answer: C. Mantoux test is read 48-72 hours after injection.
2.    Answer: A. Mantoux tests are done intradermally.
3.    Answer: D. Mantoux test is considered positive for Mycobacterium Tubercle Bacilli if the induration is 10 mm or more. For HIV positive clients, induration of 5mm is considered positive. 

This is updated once a week.
 

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